Tomchesson Insurance Agency, LLC.

Tomchesson Insurance Agency, LLC is an independent insurance agency licensed to do business only in the State of Texas. We provide insurance products for people and property located in Texas. Because we are independent we have access to multiple carriers to help serve your unique insurance needs.

Boating Insurance Quote

Please complete the following information to obtain an insurance quote. This form is for quoting purposes only. A signed and completed application is required to apply for coverage.

Driver #1

First Name:	Last Name:
Date of Birth:
Address:
City:	State:	TX
Zip:
Home Ph:	Work Ph:
Cell Ph:	Email:
Marital Status:	Occupation:
Have you been cancelled or non- renewed?	Yes No
Years of boating experience
Do you compete in fishing contests:	Yes N o
Drivers License Number:

Other Drivers

Please list the following information for any other drivers of the vehicle:

Name

Date of Birth

Driver's License #

Driver #2:

Driver #3:

Driver #4:

Driver #2

Driver #3

Driver #4

Years of boat experience:

Driving History

Accidents or claims in last 5 years regardless of fault?	Yes No
If yes, list date(s) and describe:

Tickets or Violations in last 5 years?	Yes No
If yes, list date(s) and describe:

Boat Information

Boat #1

Boat #2

Boat #3

Type of boat:

Hull Value:

Hull Year:

Hull Manufacturer:

Model:

Hull Length:

VIN:

If Outboard only:

Boat #1

Boat #2

Boat #3

Motor value:

Motor year:

Motor Manufacturer:

Motor HP/ CC:

Motor Serial Number:

Inboard/Outboard:

Boat #1

Boat #2

Boat #3

Total Boat value:

Engine HP:

Fuel Type:

Fuel Tanks vented?

Yes No

Flame/Backfire Arrestor?

Yes No

Boat Location:

If other, please list complete address:

If other please list complete address:

Type of storage:

Boat used in:

List maximum cruising speed (MPH)

Coverage Information

Current Carrier:

Effective Date:

Policy Limits

Medical Payments:		Combined Single Limits:
UM/UIM CSL:
Do you tow skiers?	Yes No
Skier's Medical?	Yes No

Deductibles
Boat & Motor Deductibles:
Trailer Value:
Trailer Manufacturer:
Trailer Deductible:
Towing:

Optional Coverage
Scheduled Boating Equipment (Depth Finders, Locations, Radios, Trolling motors:	List items and amount:
Misc Boating equipment (Life preservers, tools, Fire extinguishers, ladders, covers, chargers, batteries, etc.):	List total amount of coverage desired

Training and Licenses
Do you have a watercraft license:	Yes No If yes list:
Have you taken any boating safety courses?	Yes No If yes list:

Permission to order Claims history and insurance score.

By entering my Social Security number I hereby grant permission to Tomchesson Insurance Agency to verify my claims history, and insurance score. I agree that by granting my permission to order these reports does not bind or imply coverage at this time. I understand that these reports may only be used for the purpose of underwriting eligibility for placement of insurance coverage.

My social security number is:

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